Medicare Fraud – A Primer

BigStock_KickBackTypically, when I meet with clients for the first time, it never ceases to amaze me that they have little or no idea what constitutes Medicare fraud is and didn’t know they couldn’t be doing the things they were doing.  So, I decided to write this post to give a primer to explain: what is Medicare Fraud?

For those who are working in the medical field, whether they are doctors, corporate owners of medical practices, pharmacists, pharmacy owners, lab owners, durable medical equipment business owners, just to name a few, it can’t be overemphasized that it is essential to be familiar with the basics of Medicare fraud.

With this in mind, I want to make sure you are informed about how someone can get themselves in trouble. In general, Medicare fraud refers to submitting a false claim in a Medicare beneficiary’s name to a governmental sponsored health care program for reimbursement.

A government sponsored healthcare program includes Medicare and TriCare.  TriCare is a government sponsored health program for uniformed service members and their families, National Guard/Reserve members and their family members, including members of the: Army National Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air National Guard, Air Force Reserve, U.S. Coast Guard Reserve and their families, survivors, and their former spouses.

There is always a chance that an audit could occur.  That’s why those working in the medical field need to understand certain laws when it comes to Medicare fraud in order to maintain compliance.

  • False Claims Act: Was originally a law enacted during the Civil War to prevent unscrupulous munitions venders from defrauding the Army. It is used today to make it illegal to knowingly submit fraudulent statements to the government in order to receive federal health care reimbursements payments that the provider is not entitled to receive. For more info about the False Claims Act, click here to read The False Claims Act: A Primer available from the Department of Justice.
  • Anti-Kickback Statute (AKS): Knowingly soliciting, paying, or accepting remuneration to reward referrals for items/services that are reimbursed by federal programs.
  • Stark Law: I recently wrote more extensively about the Stark Law in a previous post. To read my post, click here. Basically, the Stark Law prohibits making referrals to an entity in which the physician or their immediate family has ownership, financial stake, or other financial compensation arrangement. If you’d like see how the AKS compares to the Stark Law, click here.
  • Criminal Fraud Statute: In a nutshell, this law prohibits knowingly executing or attempting to engage in a scheme intending to defraud a health care benefit program or provider in order to obtain money/property belonging to a health care benefit program through false pretenses.
  • Civil Monetary Penalties Law: Presenting a claim that is for an item/service not provided as claimed or one that is fraudulent or false. An example of this could also be for presenting a claim for a non-reimbursable Medicare item or service.

If you or someone you know is under investigation or has been charged with Medicare fraud, call me to schedule a confidential consultation.


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